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SAN JOAOJIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE RAW FACILITY CONTACT NAME <br /> F <br /> A C-0 OJT C c, r t ('r ltL�rc/ <br /> C <br /> I FACILITY ADDRESS SITE PHONE ! with AREA CODE <br /> L / YD /`� ' �(.r vt 1j /off - 3/0 <br /> t <br /> CITY STATE ZIP CODE f of TANKS <br /> Y � C k ><D/ S / at SITE <br /> A APPLICANT/BILLING NAME APPLICANT Cn..NTACT NAME <br /> P <br /> P GC <br /> L <br /> I NAILING ADDRESS APPLICANT PHONE 7 WITH AREA CCOE <br /> A <br /> 4 CITY / STATE ZIP CODE / TYPE of APPLICATION gp <br /> I lL1 G/ �7 sZ�S CLOSLME, INSTALLATION, etF �"�4 <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to JarAmry 1, 1991) • $100.00 <br /> I 3 <br /> V <br /> TANK FEE • 350.00/TANK (prior to J 1,n199 3170/TANK (after January 1, 1991) <br /> F t Tanks • 1 1986 1987 A1988 1989 1990 1991 1992 1995 1 1994 1 1995 1996 <br /> A (aultiply 7 by fee for U <br /> C each year applicable) 1U() a-o 3 L�3 O I S <br /> 1 <br /> L STATE SURCHARGE • $56.00 each TANK (Due ry 5 years) Set California N S Ode, Section 25247 <br /> 1 <br /> T S TanksZ z $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter arrant and year) <br /> ,j 0-0 S S(0 00 <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. Y(s) <br /> C <br /> L CLOSURE FEE • $53.00 per hour (3 hours minisam per TANK) tl TANK(s)_ X 5159.00 • 5 <br /> 0 <br /> S <br /> U MtPO Y CLOSURE (A oro-time permit, for review/irmpectiora) TANK I.D. R(s) <br /> R <br /> E TEIPCRARY CLOSURE FEE • S150.00 each TANK I TANK(s) X $150.00 • 3 <br /> P PLAN CHECK (lrataLL. Plan Review L Construction Inspections) TANK I.D. !(s) <br /> L <br /> A <br /> 4 P(AN CHECK FEE - $53.00 per hour (8 hours minis per Facility) • $424.00 minio S <br /> R REPAIR FEE (workplan review L construction inspections) TANK I.D. f(s) <br /> E <br /> P TANK REPAIR FEE • 553.00 per hour (3 hours minicuNTANK) f TANK(c) X $159.00 • S <br /> A <br /> I <br /> R PIPING REPAIR FEE 553.00 per hour (3 hour minio per facility • 5159.00) S <br /> M TRANSFER FEE . 520.00 UNAUiNCRIZED RELEASE EVALUATION • 553.00/hr S <br /> I <br /> S <br /> C CONSULTATICB FEE • 353.00/hr SAMPLING INSPECTION FEE • 353.00/hr <br /> TOTAL E S O 3 <br /> OFFICE USE ONLY <br /> searss���••.mmm— aa•'a,:a•s —s v_•��asa•w�mp �ss�L�m�11i1�f,�sip sJR <br /> I <br /> 9lifi •�•__— saa <br /> a a ccra i �..tVU�ca i I LV��.ilc I��a� �iLc I 1M1111� .L.0 I enc�/, i�t+Un I nc�cNV .1 Ci s <br /> ;.,_/'iS_G — ------1------ a <br /> i�a•.•f��1��1•aislsiii•�/mo i t...f ii ii..ice•Y.i i i i iliiiiia0•{S.i Si Pilm <br />